Defining community‐led monitoring and its role in programme‐embedded learning: lessons from the Citizen Science Project in Malawi and South Africa

Abstract Introduction Programme Science (PS) and community‐led monitoring (CLM) intersect in unexpected and promising ways. This commentary examines a CLM initiative in Malawi and South Africa to highlight the crucial role of CLM in bolstering the PS framework. By leveraging data sources often overlooked by conventional research and evaluation approaches, CLM emerges as a pivotal element in enhancing programme effectiveness. This paper delineates the fundamental principles of CLM, presents programme outcomes derived from CLM methodologies and contextualizes these findings within the broader framework of PS. Discussion The Citizen Science Project implements CLM continuously at 33 health facilities: 14 in Malawi (eight in Kasungu District and six in Dedza District), and 19 in South Africa (all in the West Rand District), representing a total catchment area of 989,848 people. Monitoring indicators are developed in an iterative process with community groups. The indicators are unique to each country, but both focus on the uptake of health services (quantitative) and barriers to access (qualitative). Monthly clinic records surveys capture 34 indicators in Malawi and 20 in South Africa and are supplemented by qualitative interviews with care recipients and healthcare workers. Qualitative interviews provide additional granularity and help confirm and explain the more macro trends in service coverage as described in quantitative data. The resulting data analysis reveals key themes that help stakeholders and decision‐makers to solve problems collaboratively. Noteworthy outcomes include a substantial increase in multi‐month dispensing of antiretroviral therapy (ART) during COVID‐19 (from 6% to 31%) with a subsequent recovery surpassing of HIV service benchmarks in Malawi post‐pandemic. Conclusions While quantifying direct impact remains challenging due to the project's design, CLM proves to be a robust methodology that generates credible data and produces impactful outcomes. Its potential extends beyond the health sector, empowering community leadership and fostering interventions aligned with community needs. As CLM continues to evolve, its integration into PS promises to improve relevance, quality and impact across diverse disciplines.


I N T R O D U C T I O N
Community-led monitoring (CLM) has the potential to strengthen programme-embedded learning by centring the lived experiences of recipients of care, empowering them to generate and analyse their own data, and using the findings to advocate for the co-creation and implementation of solutions.Community-led organizations extoll CLM as an effective mechanism for organized and systematic advocacy for the health and rights of key populations, addressing root causes of low service uptake and poor health outcomes [1][2][3].Governments also emphasize the value-add of CLM data for their own quality improvement efforts and comparison of facility-level performance [4,5].Major funding partners either require [6] or recommend [7] its inclusion in their grants.Yet, CLM remains underutilized as a mechanism to improve access to, and quality of, health services [8,9].
Programme Science (PS) is an iterative, multi-phase research and programme framework where programmes drive the scientific inquiry, and both programme and science are aligned towards a collective goal of improving population health [10].CLM is an accountability mechanism led and implemented by recipients of care that utilizes a structured platform and rigorously trained peer monitors to consistently gather and assess qualitative and quantitative data on service delivery, and to implement swift feedback loops with programme managers and health policymakers on areas requiring improvements [11].If remedial actions fail to meet community expectations, advocates utilize CLM data to escalate their advocacy strategies and hold duty-bearers accountable, including through public campaigns.
While CLM shares many principles in common with Participatory Action Research-both approaches focus on research tied to action; pay careful attention to power relationships; and situate data in their lived contexts [12]-CLM differs primarily in that it (a) mandates routine, recurring data collection that allows for the identification of trends and themes in the data, and also (b) leverages decision-making structures in which community advocates can present data on programme gaps, facilitate the co-creation of solutions and hold dutybearers accountable for change [13].Although nascent, it is a rigorous methodology that generates credible data, achieves impactful outcomes and has the potential to elevate expert community leadership well beyond HIV and the health sector [5,9,[14][15][16].
CLM has substantial potential to strengthen the PS framework by providing distinctive insights derived from community data, which may not be accessible through conventional research and evaluation approaches [2,5].CLM goes beyond quantitative analysis and reveals nuanced insights about the root causes of health systems gaps, bringing forth multifaceted, targeted solutions that are necessary to improve complex systems [17,18].CLM has led to demonstrable improvements in programme outcomes specifically because CLM data are used by communities in real time to hold dutybearers accountable for addressing identified gaps [3,9,15,16].The design of CLM upends the traditional public health hierarchy between passive "subjects" and powerful "investigators/researchers/experts," positioning recipients of care as leaders who ensure that the issues being monitored and addressed are directly relevant to their lived experiences.
By examining a CLM programme in Malawi and South Africa, this paper defines the unifying principles underpinning CLM, describes a CLM implementation model, demonstrates CLM-derived programme results, and discusses CLM's limitations and potential added value to PS.

Principles of the CLM methodology
CLM is a developing discipline with diverse implementation approaches.However, a white paper published by three civil society consortia in global health outlines shared CLM principles [19].These principles prioritize community leadership over mere community involvement.Communities lead in identifying pressing issues, defining indicators, managing data, conducting analysis (recommended in partnership with an advisory group, academic institution or other data expertise) and advocating for remedial action on identified gaps.If issues persist, communities engage in advocacy to hold duty-bearers accountable.

International Treatment Preparedness Coalition's CLM Implementation Model
This paper examines the specific implementation model pioneered by the International Treatment Preparedness Coalition (ITPC), comprised of four steps in a CLM cycle: Education, Evidence, Engagement and Advocacy [13].

Case Study: The Citizen Science CLM Programme in Malawi and South Africa
The Citizen Science project in Malawi and South Africa monitors the impact of COVID-19 on HIV and tuberculosis (TB) services, with particular attention to prevention.Since October 2020, Citizen Science CLM has been taking place at 33 health facilities: 14 in Malawi (eight in Kasungu and six in Dedza), and 19 in South Africa (all in the West Rand).Together, they serve a catchment area of 989,848 people.The implementing partners are MANERELA+ (Malawi Network of Religious Leaders Living with or Personally Affected by HIV and AIDS, based in Malawi) and NACOSA (The Networking HIV and AIDS Community of Southern Africa, based in South Africa), in partnership with grassroots community groups Access Chapter 2 and Rotanganedza Community Care (South Africa).

1.4
Step Communities receive education sessions about the science of HIV and global norms for prevention, treatment and care, followed by focus group discussions (FGDs) to determine the gaps between (a) the health services individuals should expect, and (b) their lived experiences.

Step 3: Engagement
Community implementers analyse the CLM datarecommended in partnership with an advisory group, academic institution or other data expertise-and present the results for discussion among stakeholders who can bring action to bear on the issues identified.ITPC's model recommends the creation of a Community Consultative Group (CCG) (or equivalent), a convening body of 10−15 stakeholders including recipients of care, healthcare providers, health facility managers, donors and government representatives to review the data, harvest insights and co-create solutions [13].
Beyond the CCG, Operational research indicates that CLM data collectors play a vital but often informal role in reporting CLM data to healthcare providers, sharing trends back to communities and engaging communities in HIV education.In 2023, we consulted 306 CLM stakeholders through surveys (n = 188) and interviews (n = 118).Close to half (45%) said they prefer to receive CLM feedback in real time, during data collection.Many (61%) said data collectors are present during CLM feedback sessions, often leading discussions.More than half (53%) said they remember CLM data better if a person living with HIV or key population present it to them.Healthcare workers say the "full participation of all people involved" helps them act on CLM data.One directly credits data collectors as catalysts: "It was the data collector who linked us up with the District Health Office when we had a stockout and the issue was sorted immediately."

1.7
Step 4: Advocacy When stakeholder-shared issues remain unresolved, CLM escalates to advocacy.CLM-derived insights directly trigger programme improvements: for instance, qualitative interviews identified healthcare providers' fear of losing clinical oversight as a barrier to scaling up the multi-month dispensing of antiretroviral therapy (ART).However, this concern contradicts clinical evidence, as demonstrated by a clusterrandomized trial in Malawi demonstrating non-inferiority of 6-month ART dispensing [20].Implementing partners in Malawi advocated for incorporating this evidence into clinical trainings, and documented a substantial increase in multimonth dispensing of ART during COVID-19 (from 6% to 31%).This case exemplifies CLM's ability to swiftly identify discrepancies between normative guidance and actual practice, leading to rapid improvements in service delivery, such as healthcare provider trainings, outpacing traditional PS approaches.

Evidence of CLM impact
PS approaches that centre community leadership and ownership may provide additional opportunities for impact assessment.In South Africa, our community partners leveraged their good relationship with the West Rand District Health Service to gain full access to the DHIS2 and the Stock Visibility System.This level of access provides a unique opportunity to calculate odds ratios and assess whether the targeted CLMderived interventions implemented at monitored sites correlate with improved health outcomes.Interventions include service demand generation, healthcare worker training, feedback with facility managers and engaging clinic committees on identified gaps.Sites with CLM mechanisms in place are more likely to initiate people onto pre-exposure prophylaxis (PrEP) following an HIV test (1.32 OR 95% CI 1.27−1.38),more likely to find and diagnose adolescent girls and young women living with HIV (1.46 OR 95% CI 1.28−1.66),and more likely to ensure pregnant women deliver in the health facility (1.99 OR 95% CI 1.51−2.62)[21].
CLM not only provides an immediate of reactive path to address problems, but it also offers opportunities to anticipate and mitigate potential issues within communities and programmes before they arise.For instance, during the onset of COVID-19, community data allowed for the timely identification of challenges stemming from emergency measures, such as difficulties accessing monthly ART due to lockdowns, curfews and social distancing mandates.Communities were able to use CLM to facilitate the swift implementation of remedial measures, such as multi-month dispensing, to address these challenges.
The CLM approach is not limited to using local data for local change.Community-derived indicators can also enhance global data frameworks.In September 2020, ITPC and its partners implemented data collection on multi-month dispensing of ART in response to community concerns about its importance for people living with HIV during COVID-19.This indicator's specificity and relevance extended beyond the project, leading UNAIDS to include it as a new indicator in the Global AIDS Monitoring framework in February 2022 [22].

Other CLM models
Similar CLM approaches have been successfully applied in diverse settings, including customer satisfaction surveys in Zimbabwe [3], peer-led facility exit interviews in Papua New Guinea [23], community-based focus groups and semistructured interviews in Haiti [24], "mystery shoppers" in Jamaica and the United States [25,26], clinic records surveys in Sierra Leone [2] and a mix of these methods in a regional community treatment observatory in West Africa [27].CLM frameworks should always be context-dependent and community-defined.A limited number of CLM initiatives combine both qualitative and quantitative methods, which is recommended for triangulation [11,28,29].Further, while many CLM initiatives have done well to identify problems and barriers to care, few have effectively documented how identifying these problems has led to concrete changes and programme improvements [9].

Limitations of CLM
The limitations of CLM have primarily to do with implementation.A surge in CLM investments by major bilateral and multilateral donors has led to a rush to establish CLM programmes, driven by pressure to produce primarily quantitative data and reach targets.This urgency undermines the crucial preparation steps that are necessary for the creation of effective CLM-such as the establishment of communities firmly in the lead of the process, including determining which issues will be monitored via CLM indicators; briefing of government and health facility partners on the objectives and nature of the monitoring that will take place, as there can often be scepticism when data collectors seek to begin frequenting monitoring sites; and the shared objective of CLM that is oriented towards "fact-finding" rather than "fault-finding" with the ultimate goal of service improvement.It is imperative to uphold the fidelity and rigour of the CLM model, as partial CLM or other forms of monitoring or community data collection are not equivalent.CLM implementation must be technically sound to be credible and politically viable.Likewise, multi-year programmes are best, as these allow for the ebb and flow of the relationships among all partners and enable time for the CCG mechanism to become well-established and begin producing impactful results-but funding sources often move from year to year with extremely high expectations for producing data first and foremost.
Quantifying the specific impact of CLM can be difficult.Measuring the impact of CLM is complex, as the structure of most CLM programmes does not allow for direct comparison with "control groups" that would isolate the effect of CLM.Further work is needed to triangulate control versus intervention group comparisons, such as through healthcare worker testimonials about how the intervention may have helped, alongside other qualitative and quantitative data sources.Randomized control studies on CLM are needed.

Outstanding questions for further inquiry
Significant questions remain about CLM.How many facilities must be monitored to have sufficient data to identify and initiate programme improvements?When do facilities "graduate" from CLM, and what kind of periodic evaluation is needed to sustain gains over the long term?What barriers hinder CLM data from being perceived as credible by decision-makers?And what factors determine the optimal blend of analysis, advocacy, diplomacy and accountability needed to transform CLM data from mere statistics into tangible and meaningful improvements in the lives of recipients of care?

Table 1 . Indicative quantitative and qualitative indicators for HIV-focused CLM programmes and related advocacy [13] Examples of quantitative indicators that can be collected through CLM Area Indicator Disaggregation
Key issues emerge from FGDs and shape monitoring priorities, leading to context-specific indicators unique to each CLM project in each country.Community implementers share the indicators with all relevant stakeholders, including health facility managers, municipalities and health departments to foster awareness of the areas under examination, to facilitate necessary approvals for data access and to minimize surprise when community findings are presented.Table1provides a sample of CLM indicators.